Hell On Earth
Md Niyaz
We had a patient come to the OPD with a petroclival meningioma. 45 years old, morbidly obese with a history of recent onset tendency to sway to the left while walking and difficulty hearing on the left side, all since about a year. I was not there in the OPD when he showed up for a consultation with my boss, whose primary advice for him was to lose weight. He needed to lose weight because it’s hard to wean someone morbidly obese off a ventillator, and risk of post-op loss of lower cranial nerve function in patients with any CP angle lesions makes it that much harder. The added difficulties of aspiration and ambulation in the post operative period put this man at a high risk of pneumonia and venous thromboembolism. To add to the list, he was a diabetic with uncontrolled sugars.
The man was a joyful person, full of life, who had just returned from the Middle East to have his condition addressed and risked losing his job if his return was delayed. The only bread winner in his family, Jabbar needed to keep the job to keep bringing food to the table. And the swaying did not help. It’s not possible to lose weight with a BMI > 35–40, and with imbalance. So when he returned in a couple of weeks having failed at the mammoth task, my boss admitted him realising that weight loss is not a realistic short term goal. Jabbar in the ward was a sweet old man. Smiling ear to ear when the consultants whizzed past him in the rounds. Even the day prior to his surgery I remember he was happy, did not seem too anxious, said his prayers and consented for surgery without much of a fuss.
Petroclival meningiomas can be quite tricky. Despite the relative difficulty, the surgery was uneventful.The patient was electively tracheostomised as there was a high chance of involvement of lower cranial nerves and shifted to the ICU. On POD1, he had CSF otorrhea and rhinorrhea and was reoperated and a fascial repair done. On POD 5, his sensorium dipped and they inserted an EVD assuming it must be secondary to hydrocephalus. The CSF was meningitic and IV antibiotics started. There was no improvement in his sensorium for about the next 20 days. CSF continued to be meningitic and intraventricular antibiotics were started. It’s about this time I took over the ICU.
Whenever a patient is a “chronic case” and has been unresponsive they tend to get ignored. An ICU is as such a dynamic environment, previously operated cases being shifted out on time to vacate beds for new cases coming in from the OT that day, managing the bed requirements from ward and OPD for sick cases, getting CT scans done etc. The chronic “static” patients can always “be seen later” but ‘later’ never comes because by the time it’s evening you’re too exhausted and need a breather and by the time you’re done resting it’s time to hand over the ICU to the night duty person and leave for a well deserved rest. And that probably happened with Jabbar too. The ICU person would go and make a quick assessment, “No response, tracheostomised and ventillator dependant”, and blitz past him. Physiotherapy would do joint mobility and chest care. The nurses always did an excellent job at back care twice a day. When I took over the ICU in November, I religiously instilled intraventricular antibiotics. I do not remember if I was any different towards him.
On my 3rd day in the ICU, my boss in his routine rapid rounds stopped at Jabbar with a pensive look and asked me to get a CT to look for any changes that may have evolved to explain his lack of response despite improving CSF Counts. After the CT, sir pondered and said, “ It isn’t meningitis or hydrocephalus and frankly I know the surgery went well, so we’re probably focusing on the wrong cause for global failure. Ask for a NCS and EMG. Get a CPK-MB level from the lab”. I did as told. Shifting him to the NCS lab was a difficult task considering his condition. Although we had de-escalated him off the ventillator, shifting him was a daunting task. I got it done nevertheless, anxious he may desaturate in the NCS lab. But tough times call for tough measures. (The boss at the time was a risk taker and would never compromise. He’d set the standards high and you were expected to meet it. A great man. Many a miraculous recoveries have been witnessed under his leadership, partly credited to his fearless attitude in addition to his enormous. Knowledge and experience).
The reports were in and the dreaded diagnosis stared us right in the face. It was critical illness polymyoneuropathy. The neurologist reaffirmed. When asked my boss said, “I suspected Critical care Myoneuropathy because his limbs are flabby, it’s hardly noticeable but there’s a twitch in his eyes when I call his name.” This was true. The blank staring look he had was different from the usual comatose patient. There was an unmistakeable sadness in his eyes each time when called for a response. And in hind sight, he had all the risk factors for critical illness polymyoneuropathy. He was obese, an uncontrolled diabetic and had a triggering factor in infection induced stress.
If his happy personality pre op wasn’t enough, the time and effort i had put by this time made me feel invested in Jabbar. As impressive as the diagnosis was to me, I couldn’t help but feel sorry for Jabbar who’d been conscious the whole time, staring vacantly for hours on end, trying to move, screaming within to tell us he’s there, aware. Putting myself in that condition makes me shudder to this day. Thinking of the frustration and agony he must’ve felt from not being able to respond to family members when allowed entry in to the ICU made my heart ache for him. I was emotionally invested indeed.
I remember going crazy during this time. 100 plus kilos that Jabbar was, shifting him onto an upright position was no easy feat. I’d gather the ICU staff, keep them motivated and put him on a chair, everyday. And by the end of a fortnight back spasms at the end of the day became a regular thing. We got the physiotherapists to start muscle stimulation, I’d give chest PT multiple times myself. I also had the sisters monitor his blood sugar and made sure that at no point it went beyond 200. A posterior scalp bedsore was bothersome, but I did the dressings meticulously taking utmost care not to cause any pain.
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And there came a time when we got the first response. I’d normally converse with Jabbar every time I was doing his dressings or when giving him chest physiotherapy. So you can imagine my jubilation at him nodding to one of my questions one day. I was beyond elated. This was followed by answers via blinking. Slowly over the next 2–3 days he was able to move his left upper limb against gravity and soon was able to flicker his left foot. He finally seemed to be recovering. We upped the frequency for his brother’s visit hoping it may help hasten his recovery.
Unfortunately, my time in the ICU came to an abrupt end, 4 days short of a full month. I remember that I was on duty that day and recieved a call from home at 4 am that my father had passed away. I had to leave to catch an early flight. I remember that as i was leaving I was desperately trying to give a handover of all the patient’s to my senior who was on call with me, against his wishes. He assumed I’m probably delirious from the shock of the tragedy. But it wasn’t that. In that second round of ICU postings i had unconsciously assumed ownership of the ICU and my patients, and i just could not get myself to leave without ensuring the correct information is passed on. I remember I couldn’t hold back from calling the resident replacing me to ensure he had the situation under control while waiting to board the flight in between sobs for my dad.
The next 1 month was a blur. The personal tragedy left me a mess. With the leave to finish the final rites and excuse from duties in December, I found myself entangled in the hustle bustle of the OPD and the ward patients, fighting my own demons, and soon the ICU became a background thought. The day I resumed ICU duty in Jan, it all came crashing back. In the one month that had passed, Jabbar had had another episode of infection (possibly worsening of the scalp wound) followed by subsequent uncontrolled sugars and detoriation. It was heart wrenching to see him back in the situation I initially found him. Frequent duties helped me keep a closer watch on him and I tried at least on the days i could to bring back the old routine. The occasional glimmer in his eyes, the reassuring nod or a blink made me believe we still had a shot. One evening on a Sunday duty, I was requested by the brother to let Jabbar’s wife meet him. She had come from their home town. I was surprised that this was her first visit in 4 months, but I suppose with children to take care the roles were divided.
I saw her enter the ICU composed, a gentle smile on her face and very kind eyes. The lady spoke to him in a sweet tone and told him how the children were doing, about his parents and the ‘what’s happenings’ around town. After about 15 minutes, it was time for the lady to go.
That night when I was doing a quick round up of the ICU before hitting the sac, I saw Jabbar, facial expression sad, tears rolling down his cheeks. I asked him, “ What happened Jabbar?” And told him that i know it’s hard but things will get better and not to give up. But i never got the reassuring nod this time.
The next day Jabbar became unresponsive again and the following day we declared him dead, despite all resuscitative efforts, at 4 am.
It breaks my heart to think about it even today. If there ever was hell on earth. Completely aware, yet not even able to move a muscle. Not able to hug his wife in front of him, to ask more about the kids. And the fact that he was the sole bread winner makes my heart ache for his wife and children.
Critical illness polymyoneuropathy with elevated CK MB levels usually portends a poor prognosis. Less than 50% of the people recover at 6 months and even the ones that recover have associated morbidity. Cases like Jabbar make me realise that this isn’t just another job. This is a blessing. An opportunity to see life and it’s unfairness upfront. To keep your priorities sorted, and you humble.
There’s much to be done and the only way forward is through dedicated effort.
